Helping Quitters Win: OTC Meds for Smoking Cessation

Justin J. Sherman, PharmD

Published Online: Sunday, April 1, 2007

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Quitting smoking is at the top
of the resolutions list for
most smokers, and each year
the enthusiastic quitter will stop for a
dayor maybe even 2. Unfortunately,
most smokers fail on their first try.
After learning how difficult quitting is,
many will never attempt such a feat
again.

What is wrong with this scenario?
Plenty, including the possibilities that
the smoker lacked a definite quit plan,
did not seek individual and/or group
help, did not substantially modify his or
her behavior, and, perhaps, did not
receive assistance regarding a medication
choice.

Which Medication Works Best?

This is a common question because
smokers want a medication that will be
a sure-fire cure. In truth, that medication
does not exist. Although a void
exists for head-to-head trials that
include all smoking-cessation medications,
each has been shown to help
twice as many smokers quit, when
compared with placebo.1 Thus, all medications
are equally efficacious and
better than quitting cold turkey when
used properly. This is true even with
prescription-only choices.

The choice of medication should be
individualized, however. What factors
should be considered in this choice?
For patients new to cessation medication,
the unique benefits and potential
adverse effects of each medication
should be explained. Also, the choice
should be based on previous success/
failure with a medication, unique characteristics
of the patient's cravings,
and patient preference.

Should the Patient SwitchMedications?

In general, patients should be
encouraged to use medications that
have brought past success. Even if the
patient's success was moderate with a
particular medication, he or she may
wish to try it again, combined with a
more definitive quit plan. If the previous
failure was due to an adverse
effect, however, trying a different medication
this time may be more
beneficial.

The pharmacist should discern the
specific reason for the previous failure.
If the roadblock was an adverse effect,
the patient may not have known how to
overcome the problem. For example, a
significant number of nicotine patch
users can develop skin irritation.2 These
patients whose cravings were alleviated
with the patch could use OTC hydrocortisone
cream and rotate their patches
more frequently. Since the adhesive
of a particular brandand not the
strength of the patch (a common misconception)causes the skin irritation,
switching to another brand is often
effective for this problem. Likewise,
some patients stop using nicotine gum
due to gastrointestinal distress. This is
often because they chew nicotine gum
like any other gum. They should chew
nicotine gum slowly, then park it
between the cheek and gum once a
"peppery" taste emerges.

Also, patients often mistake nicotine-withdrawal
symptoms for adverse
effects, including increased irritability,
coughing, sweating, nervousness, insomnia,
and vivid dreams. These symptoms
can derail a cessation attempt
when combined with intense cravings.
The pharmacist should distinguish
whether withdrawal symptoms or an
actual adverse effect caused the previous
relapse before suggesting another
medication.

Counseling the Patient

OTC cessation medications are nicotine-replacement therapies (NRTs),
including nicotine gum, lozenges, and
patches. Each is appropriate first-line
therapy, except for patients with
underlying cardiovascular disease
(recent myocardial infarction, severe
angina, or life-threatening arrhythmias)
and pregnant or lactating women.
Without counseling, many patients
misuse nicotine gum. If patients smoke
>25 cigarettes per day, they should use
4 mg. If they smoke less, 2 mg is appropriate.
Unless the gum is for combination
therapy, the patient should chew
according to a fixed schedule. This
retrains the patient not to respond to
cravings with nicotine. The patient
should chew 1 piece every 1 to 2 hours
for weeks 1 through 6, every 2 to 4
hours for weeks 7 through 9, and every
4 to 8 hours for weeks 10
through 12. Successful users
chew an average of 9 pieces
per day. Also, acidic beverages
can decrease efficacy if
consumed up to 15 minutes
before or concurrently with
the gum. The first sign of a
peppery or minty taste
occurs after about 15 to 30
chews. Then, as noted, the
patient should tuck the gum
between the cheek and gum
and resume chewing when
the taste fades. Most nicotine
is buccally absorbed
within 30 minutes.3

Counseling for the lozenge is similar
to that for the gum, except that the
recommended dose is determined differently.
If the first cigarette is smoked
within 30 minutes of awakening, 4 mg
is appropriate. Also, the lozenge dissolves
slowly; patients should not
chew, bite, or swallow the lozenge.
Finally, whereas the gum may delay
weight gain for some patients, the
lozenge will not.4

For many patients, the patch is easy
to use. Patients should apply it daily
upon awakeningit can cause insomnia
and vivid dreams if applied at bedtimeto a hairless part of the upper
body. They should rotate application
areas daily and remove the patches at
bedtime. The onset of effect will be
about 30 minutes, and mild tingling
and itching can occur. If the patient is
smoking >10 cigarettes per day, he or
she should start with the highest dose
(21 mg) for 6 weeks; then the 14-mg
and 7-mg doses can be used for 2
weeks each. Also, patients should not
cut patches, reuse them, or place
them on compromised skin. Patches
can be exposed to showering or
bathing, however.5

NRTs:Trading One Addiction forAnother?

Even with the gum, nicotine delivered
as NRT does not have as quick an
onset as the bolus dose delivered with
cigarettes.6 This is an important difference,
because bolus dosing
leads to increased cravings.
Although NRTs will attenuate
cravings, they will not
be entirely eliminated. Thus,
patients should be given
other tools, like an individualized
quit plan, to combat
cravings. Finally, if the patch
or gum is being used beyond
the titration schedule,
pharmacists can offer some
helpful strategies: chewing
regular gum in place of
nicotine gum, using the
gum or patch for half the
allotted time, or using it every other
day instead of daily.

Can Patients Use Combinations?

Studies are conflicting regarding
combined nicotine patches and
gums.7,8 Long-time nicotine users of 2
or more packs per day with several
unsuccessful attempts via monotherapy
may be candidates, however. A
basal NRT, such as a patch, could be
combined with as-needed use of a
gum or lozenge for breakthrough cravings.
This is similar to the principle for
pain-management medications. It
should be noted that levels of nicotine
with combination therapy may exceed
recommendations, so only selected
patients may benefit. Thus, pharmacists
should proceed with caution.

Helping with a Quit Plan

To maximize success, pharmacotherapy
is combined with a concrete quit
plan. It is essential that patients recognize
that long-term success depends
on a complete behavioral change. They
should take steps even before the quit
date, such as obtaining group and/or
family support, anticipating what
causes cravings, and removing tobacco
products from the household. NRT
should be started on the quit date, and
relapse-prevention counseling should
begin as soon as possible. Counseling
for behavioral change and cognitive
stress management are also helpful.

Lack of follow-up by a health care
provider is another common cause of
relapse. The pharmacist should follow
up soon after the quit date, either by
phone or scheduled visit. If the pharmacist
needs further training on smoking
cessation, several programs are
available, such as the "Prescription for
Change" program from the University
of California at San Francisco, and the
University of Pittsburgh's certificate
program.9 A wide variety of programs
are available for smokers, including
Internet sites, Nicotine Anonymous
programs, and programs sponsored by
state chapters of the American Heart
Association.

Dr. Sherman is an associate professorof pharmacy practice at theUniversity of Louisiana at MonroeCollege of Pharmacy.